- Email: [email protected]
A tribute to Panna Choudhury, MD
December 2015 Volume 167 Number 6
Welcoming a new Associate Editor to The Journal — William F. Balistreri, MD
Copyright ª 2015 by Elsevier Inc.
I
t is with regret but warm wishes that I announce that Alan H. Jobe, MD, PhD, will be stepping down from his Associate Editor role at the end of 2015. Dr Jobe played, and continues to play, a pivotal role in making The Journal the “go to” journal for high-impact neonatology research. Despite his personal “10-year rule” (“after 10 years for any academic position, new leadership should come from someone else– preferably younger–who is given the opportunity”), he has broken this rule and continued as an Associate Editor for 18 years “because I have very much enjoyed serving as a referee for some of the best research in neonatology that is being submitted to The Journal.” Dr Jobe plans to expand his involvement in international research through the Eunice Kennedy Shriver National Institute of Child Health and Human Development Global Research Network. He will continue with active animal model research programs focusing on antenatal corticosteroids, fetal inflammation, and prematurity in association with colleagues at the University of California Davis National Primate Research Center and at the University of Western Australia, and will remain active both clinically and with teaching. Although Dr Jobe will be missed as an Associate Editor, we are pleased that he will continue his relationship with The Journal by serving as an Editorial Board member beginning in 2016. With the approaching departure of an Associate Editor, we started the search for a new Associate Editor to join The Journal’s leadership. After assessing outside candidates as well as the pool of current Editorial Board members, we have chosen someone who we believe will continue to attract high quality neonatology research to The Journal and who will excel as an Associate Editor. We would like to welcome and introduce Robin H. Steinhorn, MD, as The Journal’s newest Associate Editor. Dr Steinhorn began handling new manuscripts in September. Robin H. Steinhorn, MD, joined Children’s National Medical Center in September 2015 as the Senior Vice President for Hospital Based Specialties. Prior to arriving at Children’s National, she served as Chair of the Department of Pediatrics at the University of California Davis and Pediatrician in Chief for the UC Davis Children’s Hospital. Dr Steinhorn is a member of the Council of the American Pediatric Society and serves on the American Board of Pediatrics for Neonatal Perinatal Medicine. She is an elected Fellow of the American Heart Association and a member of the Perinatal Research Society and American Thoracic Society. Dr Steinhorn’s clinical and academic interests have primarily been focused on the pulmonary vascular development of the fetus and newborn. Her translational work has spanned from in vitro studies to animal models, and she has contributed to numerous multicenter trials that have helped define the clinical treatment of pulmonary hypertension in the neonatal period. Her recent clinical research also has addressed telemedicine support of neonatal care in rural hospitals. She is married to a pediatric intensivist and has two children pursuing medical careers. She looks forward to carrying on Dr Jobe’s legacy of publishing high-impact neonatal research in The Journal, and continuing to support trainees and young investigators as they navigate presenting and publishing their research findings. (Continues on next page) 1179
Got shunt. Need CT? — Paul G. Fisher, MD
Quality of life may not reflect quality of sleep — Denise M. Goodman, MD, MS
1180
A
ny physician who has taken call in the emergency department (ED) knows that children with ventriculoperitoneal shunts present often with fever, lethargy, or other complaints, and then pose a dilemma about whom should undergo evaluation for shunt failure with head computed tomography (CT). Are we needlessly irradiating some children with repetitive head CTs? In this issue of The Journal, Florin et al utilize the Pediatric Health Information System database from 31 children’s hospitals to examine what happened over the next 10 years to a cohort of 1319 children following initial shunt placement when they presented to the ED. Nearly one-half of all ED visits for these children were associated a head CT. The rate of CT among these patients varied widely and significantly across hospitals and was also associated statistically with the principal, underlying diagnosis. Perhaps most striking was the finding that just under 6% of the children accounted for close to 40% of all ED visits coupled with a CT. These patients received cumulatively >10 CTs. However, these children were least likely to undergo a shunt revision. Clearly we have much work ahead of us to remedy this mismatch. Not only do we need better ways to improve our sensitivity and specificity in the use of CT to identify children with shunts truly needing repair, but also we need to find ways to “shunt” these high-risk children to radiation-sparing rapid sequence brain magnetic resonance imaging (MRI) rather than radiation-based CT. Few children in this study underwent rapid MRI. The finding that nearly 1 in 6 of the children undergoing CT were exposed to cumulative radiation dose >20 mSV, linked with a risk of cancer, cannot be condoned. Moreover, because 4 of the 5 children undergoing CT did not require a revision, we need to refine better who needs imaging and then find a way to make these MRIs. Article page 1382<
I
n this issue of The Journal, a small clinical study assessed the residual psychosocial impairments of sleep disordered breathing (SDB), comparing those with and without sleep symptom resolution and healthy controls. Patients were examined at ages 3-5 years and again at ages 6-8 years. Outcomes included health-related quality of life, general quality of life, family functioning, and parental stress, and formal polysomnography was performed at both time points. Health-related quality of life using a sleep-specific instrument, the OSA-18, showed poorer quality of life for those with sleep disturbance compared with controls, and there was no difference between those for whom SDB had resolved vs those with unresolved SDB at follow-up. This observation held despite some improvement at follow-up compared with baseline measures. For many aspects of general quality of life, there was no difference between groups with unresolved and resolved SDB, with the exception of family social functioning, which was poorer in the resolved group than the unresolved or control groups. Improved obstructive apnea hypopnea index (OAHI) was associated with better school performance, less family worry, and improved family relationships. Lastly, most aspects of parental stress did not change between baseline and follow-up, regardless of whether SDB resolved. For many domains, psychosocial functioning at ages 6-8 years was poorer for those children diagnosed with SDB at ages 3-5 years than for controls, even if the SDB resolved by ages 6-8 years. That said, any improvement is likely related in part to disease severity. It is not possible to dissect whether this is because early SDB has an irreversible developmental affect, or rather that behavioral difficulties were the principal drivers of psychosocial issues such that resolution of the respiratory symptoms has no influence on psychosocial outcomes. Importantly, these data add to growing recognition that improvements in polysomnography do not necessarily translate to improvements in important psychosocial outcomes. Conversely, even mild disease may have long term affects, meriting close follow-up throughout childhood. Article page 1272< Vol. 167, No. 6
Discussing impending death from cancer — Paul G. Fisher, MD
Looks can be deceiving in neuromuscular disease — Paul G. Fisher, MD
High cost effectiveness of newborn screening for sickle cell disease in resource-limited Angola — Sarah S. Long, MD
December 2015
C
ancer remains the disease that leads to the most deaths in children, despite improvements in diagnosis and therapy. Although accidents, homicide, and trauma account for more deaths at some ages, none of these share with cancer the looming latency period before a child loses his or her life. Practitioners, parents, and children can feel ill at ease about what topics should be discussed, particularly that of the impending death. In this issue of The Journal, van der Geest et al investigate among a cohort of 86 parents and 56 children with terminal cancer whether the parents discussed the approaching death, why some did not, and how they felt about their decision. About one-third of parents did discuss death with the child. Among the other two-thirds, reasons cited for not initiating a discussion included parents’ inability to start the conversation, parents’ desire to protect the child, children’s unwillingness to talk or their underlying disability, or lack of an opportunity. Most parents felt positive about their decision, regardless of whether they discussed death with their child. Clearly, issues regarding what to discuss or not discuss at the end of a child’s life are complex. There is no one ideal conversation. There also is no one right path to take in palliative care. Clinicians should be supportive regardless of parents’ decisions. More research in palliative care is needed to guide pediatricians on how best to support families at the end of a child’s life, whether anticipated or sudden. The Journal applauds such investigations and welcomes manuscripts advancing research in palliative care. End of life care for children has all too often been unexplored. Further insights should help affected families. Article page 1320<
C
hildren with spinal muscular atrophy and other neurologic diseases may appear small or even cachectic, but their body composition and basic metabolism often have been overlooked. In this issue of The Journal, Hurst Davis et al set out to examine in a rigorous fashion the effects of fasting and glucose tolerance in a pilot cohort of 6 children with spinal muscular atrophy type II. By use of dual energy x-ray absorptiometry, all 6 participants were deemed obese, despite their phenotypic appearance. By using body mass index for age percentiles, only one-half were considered obese. On average, fat composed 72% of body mass. Oral glucose tolerance was highly impaired with the participants exhibiting hyperinsulinemia and insulin resistance. Hemoglobin A1c levels did not accurately reflect the degree of glucose metabolism. The children all tolerated a 20-hour fast, but again demonstrated insulin resistance and no hyperglucagonemia. This study puts into perspective the importance of obesity management in spinal muscular atrophy and other neuromuscular diseases. We should not be fooled into thinking that children with neurologic disease who at first glance appear small for age are not obese or not prone to impaired glucose metabolism. Further study is needed, along with attention to the nutritional status of these children. Article page 1362<
I
n this issue of The Journal, McCann et al provide rare cost and cost-effectiveness analyses of a healthcare intervention in Africa. They show that a pilot screening program for sickle cell disease in newborns in Luanda, Angola, and enrollment of affected infants into a care and education program were highly cost effective in terms of healthy life-years gained during the first 5 years of life. Their findings help to enlighten arguments made against newborn screening in resource-limited countries. Their use of standard analytic methodology and World Health Organization and Global Burden of Disease Study 2010 estimates of mortality in the Angolan population make the study a reliable benchmark for Angola and provides a template for replicable methodology for other countries. Article page 1314<
1181
A tribute to Panna Choudhury, MD — Monica L. Helton, BA — William F. Balistreri, MD
1182
W
e are saddened to report that our friend and colleague, Panna Choudhury, MD, died on September 1, 2015. His enthusiasm and dedication to the field of pediatrics as a whole, in India and globally, is evident by the following examples: National President of the Indian Academy of Pediatrics (2009); Editor-in-Chief, Indian Pediatrics (2002-2007); Editorial Board member of The Journal of Pediatrics (2012-2015); and Co-Founder and Vice Chairman of the Child Health Foundation. Annually, he flew thousands of miles for the sole purpose of attending our one-day Editorial Board meetings, only to turn around and travel back home in Uttar Pradesh, India. He will be greatly missed.
Vol. 167, No. 6
Welcoming a new Associate Editor to The Journal — William F. Balistreri, MD
Copyright ª 2015 by Elsevier Inc.
I
t is with regret but warm wishes that I announce that Alan H. Jobe, MD, PhD, will be stepping down from his Associate Editor role at the end of 2015. Dr Jobe played, and continues to play, a pivotal role in making The Journal the “go to” journal for high-impact neonatology research. Despite his personal “10-year rule” (“after 10 years for any academic position, new leadership should come from someone else– preferably younger–who is given the opportunity”), he has broken this rule and continued as an Associate Editor for 18 years “because I have very much enjoyed serving as a referee for some of the best research in neonatology that is being submitted to The Journal.” Dr Jobe plans to expand his involvement in international research through the Eunice Kennedy Shriver National Institute of Child Health and Human Development Global Research Network. He will continue with active animal model research programs focusing on antenatal corticosteroids, fetal inflammation, and prematurity in association with colleagues at the University of California Davis National Primate Research Center and at the University of Western Australia, and will remain active both clinically and with teaching. Although Dr Jobe will be missed as an Associate Editor, we are pleased that he will continue his relationship with The Journal by serving as an Editorial Board member beginning in 2016. With the approaching departure of an Associate Editor, we started the search for a new Associate Editor to join The Journal’s leadership. After assessing outside candidates as well as the pool of current Editorial Board members, we have chosen someone who we believe will continue to attract high quality neonatology research to The Journal and who will excel as an Associate Editor. We would like to welcome and introduce Robin H. Steinhorn, MD, as The Journal’s newest Associate Editor. Dr Steinhorn began handling new manuscripts in September. Robin H. Steinhorn, MD, joined Children’s National Medical Center in September 2015 as the Senior Vice President for Hospital Based Specialties. Prior to arriving at Children’s National, she served as Chair of the Department of Pediatrics at the University of California Davis and Pediatrician in Chief for the UC Davis Children’s Hospital. Dr Steinhorn is a member of the Council of the American Pediatric Society and serves on the American Board of Pediatrics for Neonatal Perinatal Medicine. She is an elected Fellow of the American Heart Association and a member of the Perinatal Research Society and American Thoracic Society. Dr Steinhorn’s clinical and academic interests have primarily been focused on the pulmonary vascular development of the fetus and newborn. Her translational work has spanned from in vitro studies to animal models, and she has contributed to numerous multicenter trials that have helped define the clinical treatment of pulmonary hypertension in the neonatal period. Her recent clinical research also has addressed telemedicine support of neonatal care in rural hospitals. She is married to a pediatric intensivist and has two children pursuing medical careers. She looks forward to carrying on Dr Jobe’s legacy of publishing high-impact neonatal research in The Journal, and continuing to support trainees and young investigators as they navigate presenting and publishing their research findings. (Continues on next page) 1179
Got shunt. Need CT? — Paul G. Fisher, MD
Quality of life may not reflect quality of sleep — Denise M. Goodman, MD, MS
1180
A
ny physician who has taken call in the emergency department (ED) knows that children with ventriculoperitoneal shunts present often with fever, lethargy, or other complaints, and then pose a dilemma about whom should undergo evaluation for shunt failure with head computed tomography (CT). Are we needlessly irradiating some children with repetitive head CTs? In this issue of The Journal, Florin et al utilize the Pediatric Health Information System database from 31 children’s hospitals to examine what happened over the next 10 years to a cohort of 1319 children following initial shunt placement when they presented to the ED. Nearly one-half of all ED visits for these children were associated a head CT. The rate of CT among these patients varied widely and significantly across hospitals and was also associated statistically with the principal, underlying diagnosis. Perhaps most striking was the finding that just under 6% of the children accounted for close to 40% of all ED visits coupled with a CT. These patients received cumulatively >10 CTs. However, these children were least likely to undergo a shunt revision. Clearly we have much work ahead of us to remedy this mismatch. Not only do we need better ways to improve our sensitivity and specificity in the use of CT to identify children with shunts truly needing repair, but also we need to find ways to “shunt” these high-risk children to radiation-sparing rapid sequence brain magnetic resonance imaging (MRI) rather than radiation-based CT. Few children in this study underwent rapid MRI. The finding that nearly 1 in 6 of the children undergoing CT were exposed to cumulative radiation dose >20 mSV, linked with a risk of cancer, cannot be condoned. Moreover, because 4 of the 5 children undergoing CT did not require a revision, we need to refine better who needs imaging and then find a way to make these MRIs. Article page 1382<
I
n this issue of The Journal, a small clinical study assessed the residual psychosocial impairments of sleep disordered breathing (SDB), comparing those with and without sleep symptom resolution and healthy controls. Patients were examined at ages 3-5 years and again at ages 6-8 years. Outcomes included health-related quality of life, general quality of life, family functioning, and parental stress, and formal polysomnography was performed at both time points. Health-related quality of life using a sleep-specific instrument, the OSA-18, showed poorer quality of life for those with sleep disturbance compared with controls, and there was no difference between those for whom SDB had resolved vs those with unresolved SDB at follow-up. This observation held despite some improvement at follow-up compared with baseline measures. For many aspects of general quality of life, there was no difference between groups with unresolved and resolved SDB, with the exception of family social functioning, which was poorer in the resolved group than the unresolved or control groups. Improved obstructive apnea hypopnea index (OAHI) was associated with better school performance, less family worry, and improved family relationships. Lastly, most aspects of parental stress did not change between baseline and follow-up, regardless of whether SDB resolved. For many domains, psychosocial functioning at ages 6-8 years was poorer for those children diagnosed with SDB at ages 3-5 years than for controls, even if the SDB resolved by ages 6-8 years. That said, any improvement is likely related in part to disease severity. It is not possible to dissect whether this is because early SDB has an irreversible developmental affect, or rather that behavioral difficulties were the principal drivers of psychosocial issues such that resolution of the respiratory symptoms has no influence on psychosocial outcomes. Importantly, these data add to growing recognition that improvements in polysomnography do not necessarily translate to improvements in important psychosocial outcomes. Conversely, even mild disease may have long term affects, meriting close follow-up throughout childhood. Article page 1272< Vol. 167, No. 6
Discussing impending death from cancer — Paul G. Fisher, MD
Looks can be deceiving in neuromuscular disease — Paul G. Fisher, MD
High cost effectiveness of newborn screening for sickle cell disease in resource-limited Angola — Sarah S. Long, MD
December 2015
C
ancer remains the disease that leads to the most deaths in children, despite improvements in diagnosis and therapy. Although accidents, homicide, and trauma account for more deaths at some ages, none of these share with cancer the looming latency period before a child loses his or her life. Practitioners, parents, and children can feel ill at ease about what topics should be discussed, particularly that of the impending death. In this issue of The Journal, van der Geest et al investigate among a cohort of 86 parents and 56 children with terminal cancer whether the parents discussed the approaching death, why some did not, and how they felt about their decision. About one-third of parents did discuss death with the child. Among the other two-thirds, reasons cited for not initiating a discussion included parents’ inability to start the conversation, parents’ desire to protect the child, children’s unwillingness to talk or their underlying disability, or lack of an opportunity. Most parents felt positive about their decision, regardless of whether they discussed death with their child. Clearly, issues regarding what to discuss or not discuss at the end of a child’s life are complex. There is no one ideal conversation. There also is no one right path to take in palliative care. Clinicians should be supportive regardless of parents’ decisions. More research in palliative care is needed to guide pediatricians on how best to support families at the end of a child’s life, whether anticipated or sudden. The Journal applauds such investigations and welcomes manuscripts advancing research in palliative care. End of life care for children has all too often been unexplored. Further insights should help affected families. Article page 1320<
C
hildren with spinal muscular atrophy and other neurologic diseases may appear small or even cachectic, but their body composition and basic metabolism often have been overlooked. In this issue of The Journal, Hurst Davis et al set out to examine in a rigorous fashion the effects of fasting and glucose tolerance in a pilot cohort of 6 children with spinal muscular atrophy type II. By use of dual energy x-ray absorptiometry, all 6 participants were deemed obese, despite their phenotypic appearance. By using body mass index for age percentiles, only one-half were considered obese. On average, fat composed 72% of body mass. Oral glucose tolerance was highly impaired with the participants exhibiting hyperinsulinemia and insulin resistance. Hemoglobin A1c levels did not accurately reflect the degree of glucose metabolism. The children all tolerated a 20-hour fast, but again demonstrated insulin resistance and no hyperglucagonemia. This study puts into perspective the importance of obesity management in spinal muscular atrophy and other neuromuscular diseases. We should not be fooled into thinking that children with neurologic disease who at first glance appear small for age are not obese or not prone to impaired glucose metabolism. Further study is needed, along with attention to the nutritional status of these children. Article page 1362<
I
n this issue of The Journal, McCann et al provide rare cost and cost-effectiveness analyses of a healthcare intervention in Africa. They show that a pilot screening program for sickle cell disease in newborns in Luanda, Angola, and enrollment of affected infants into a care and education program were highly cost effective in terms of healthy life-years gained during the first 5 years of life. Their findings help to enlighten arguments made against newborn screening in resource-limited countries. Their use of standard analytic methodology and World Health Organization and Global Burden of Disease Study 2010 estimates of mortality in the Angolan population make the study a reliable benchmark for Angola and provides a template for replicable methodology for other countries. Article page 1314<
1181
A tribute to Panna Choudhury, MD — Monica L. Helton, BA — William F. Balistreri, MD
1182
W
e are saddened to report that our friend and colleague, Panna Choudhury, MD, died on September 1, 2015. His enthusiasm and dedication to the field of pediatrics as a whole, in India and globally, is evident by the following examples: National President of the Indian Academy of Pediatrics (2009); Editor-in-Chief, Indian Pediatrics (2002-2007); Editorial Board member of The Journal of Pediatrics (2012-2015); and Co-Founder and Vice Chairman of the Child Health Foundation. Annually, he flew thousands of miles for the sole purpose of attending our one-day Editorial Board meetings, only to turn around and travel back home in Uttar Pradesh, India. He will be greatly missed.
Vol. 167, No. 6